The Family Physician.

Because they often provide care for every member of a family, family physicians have the opportunity to observe and treat the repercussions of one person's alcohol problem on all family members. Recent trends in diagnosis and treatment of alcohol-related disorders have encouraged greater involvement by family physicians in the care of a patient with alcohol problems.


A lcoholrelated disorders are
The second family member to became suspicious that the parents could among the most common seek medical attention was Paul's have a problem with alcohol during the medical disorders family older sister, Mary, who was 16 daughter's prenatal visit. Her suspicion physicians encounter in their years old and pregnant. During a was confirmed with the appearance of the practices (Brown 1992). Family physi prenatal examination that the family mother. If the family practitioner had seen cians have developed many of the skills physician conducted, Mary revealed only one family member, as often occurs practiced by internists, obstetricians, a history of sexual abuse as a child. in a specialist's office, she would have psychiatrists, pediatricians, and geriatri The physician also noted that Mary been less likely to identify the primary cians and possess a breadth of expertise was depressed and suicidal. issue affecting this family. It is easy to that gives them special abilities to detect The third family member to seek focus on an individual with a medical and treat the alcohol and other drug prob medical attention was Mary and problem such as headaches, adolescent lems they see in their practices. In addi Paul's mother, Margaret, who want pregnancy, sleeping problems, or chronic tion, because these physicians often work ed something for her nerves. She abdominal pain and to overlook the rela with entire families, they are in a unique was having difficulty sleeping. On tionship between these problems and an alcohol problem in the family. position to observe relationships among further questioning, Margaret admit A further strength inherent in the role the family members and the effect that ted to daily alcohol use and a family of the family physician is the opportunity one person's alcoholism has on the family. history of alcoholism. to develop a trusting, supportive relation The following case illustrates some of The last family member to seek ship with all the family members. Caring these opportunities. medical attention from the family for patients over a long period of time physician was Mary and Paul's allows family physicians more occasions A family of four, after relocating in father, John. He wanted a refill of to discuss sensitive issues and increases south central Wisconsin, chose a his "stomach medication" that he the likelihood of their being able to help family physician as their primary had received from his previous patients change behaviors such as destruc care physician from a list of physi physician. During the routine exam tive alcohol use. cians provided by their health main ination, the family physician also Family physicians receive extensive tenance organization.
noted that John had hypertension training in public health issues of medical The first family member to seek and a history of alcohol withdrawal. care during their residency training pro medical attention from the family grams, which is essential for the primary physician was the 8yearold boy, Each of the family members was and secondary prevention of alcohol Paul, who had chronic headaches. affected in some way by the alcohol abuse problems. Primary prevention involves A neurological examination was in the family. The family physician first averting problems; secondary prevention completed and revealed no struc involves early intervention before prob tural lesion or other medical prob KRISTEN L. BARRY and using brief and simple intervention techniques. The methods family physi cians learn minimize the use of costly hightech diagnostic and treatment meth ods, which helps to reduce overall health care costs while providing patients with earlier, more appropriate, and less inva sive care options. Training family physicians in the public health model corresponds to recent shifts in theories of prevention and treat ment of alcoholrelated problems. For instance, we now recognize that: • The majority of people experiencing health problems secondary to their alcohol and other drug use are atrisk users rather than alcoholics and ad dicts (Fleming and Barry 1992).
• There is a direct correlation between levels of alcohol consumption and health effects. Adverse effects begin to occur at 12 drinks per week for wom en and 15 drinks per week for men. Binge drinking (five or more drinks per occasion) also is correlated with health effects, in particular, with trau matic injuries (Anderson et al. 1993;SanchezCraig et al. in press; National Institute on Alcohol Abuse and Alco holism [NIAAA] 1992).
• Primary care clinicians can identify and effectively treat the majority of persons and families adversely affect ed by alcohol and other drug disorders (Saunders et al. 1993).
• Several specialized treatment methods in addition to the traditional 12step treatment programs can help people change their use of alcohol and other drugs (Hester and Miller 1989).
This article will focus on these shifts in thinking and their effect on the family physician's ability to diagnose disorders related to and care for persons adversely affected by alcohol and other drug use.

PREVALENCE OF ALCOHOL DISORDERS IN FAMILY MEDICINE
Alcohol disorders include alcohol de pendence and abuse and atrisk use. Alcoholism, dependence, and abuse are defined using the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; 1994) criteria for alco hol abuse and dependence. Atrisk use is defined as men who drink 15 or more drinks per week, women who drink 12 or more drinks per week, or those of either gender who binge drink. The prevalence of a current diagnosis of alcoholism in pri mary care settings is 5 to 8 percent for men and 2 to 3 percent for women (Fleming and Barry 1992). Preliminary findings from a survey of 17,298 adults taken by physi cians in southern Wisconsin, however, indicate that the prevalence of atrisk drinking is 15 to 20 percent for men and 8 to 10 percent for women. According to the preliminary data, approximately onefifth of men drink 15 or more drinks per week, and 1 in 8 drink 3 or more drinks per day. By comparison, women engage in atrisk drinking less often than men.

RECOGNITION OF ATRISK DRINKERS
Atrisk drinkers have been recognized as having the majority of alcoholrelated problems; this has led to two changes in Atrisk drinkers also make up the largest percentage of drinkers with problems in primary care practices. Intervention at this stage has the potential to circumvent more severe social, medical, and psycho logical problems. Indeed, epidemiologic research has established a direct relationship between alcohol use and alcoholrelated problems. Put simply, the more a person drinks, the greater the number of problems he or she will have (Anderson et al. 1993;NIAAA 1992;SanchezCraig et al. in press). This pattern is true for most alcoholinduced health problems such as stroke, trauma, depression, heart disease, hypertension, mental status changes, alcoholrelated birth defects, and alcoholic liver disease (Anderson et al. 1993;NIAAA 1992;SanchezCraig et al. in press). Table 1 lists the warning signs of alcohol problems commonly seen in primary care settings.
In light of the relationship between alcohol use and alcoholrelated problems, a second change in diagnosis and clinical care has been the realization that questions about consumption are useful screening questions and provide a method to catego rize respondents into levels of risk for alcoholrelated problems. The data are similar to data obtained for hypertension or hypercholesterolemia (excess of choles terol in the blood), in which specific cutoff points of cholesterol levels are used to assess level of risk. For example, a white middleage man with a cholesterol level above 280 mg percent has a twofold risk of developing cardiovascular disease, compared with a man with a cholesterol level below 200 mg percent.
The traditional assumption that all patients who drink tend to underreport their alcohol use is not supported by research (Babor et al. 1989). People who are not alcohol dependent or intoxicated during screening often provide accurate information. Methods that are known to increase the accuracy of selfreporting include asking specific questions about use in the recent past, using a direct non judgmental approach, embedding the alcoholuse questions in the context of other health behaviors such as smoking and exercise, and paying attention to nonverbal cues that suggest that the pa tient is minimizing his or her alcohol use. Some nonverbal cues include blushing, fidgeting, turning away, looking down at the floor, and a marked change in the breathing pattern.
Specific recommended screening questions about consumption include the following: About how many days per week do you drink alcohol? On a day when you do drink, how much do you drink? How many days per month do you have five or more drinks? These are often the first questions family physicians ask patients they suspect as having alcohol related problems.
It may be useful to follow consump tion questions with the CAGE questions (Ewing 1984) (acronym for "Have you ever felt you should CUT down on your drinking?" "Have people ANNOYED you by criticizing your drinking?" "Have you ever felt bad or GUILTY about your drink ing?" "Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover [EYE open er]?"). Further queries about prior conse quences of drinking are then useful. (For more information on screening instru ments that may be helpful to family physicians, see Nilssen and Cone, pp. 136-139.) Once a patient has screened positive for atrisk drinking, a family physician should assess that patient for evidence of physical dependence; the presence of serious alcoholrelated health problems; use of illicit drugs; and social, legal, family, and employment problems. This information will facilitate the next step and assist the family physician in devel oping a treatment plan for the patient.

BRIEF INTERVENTIONS: THE FIRST STAGE IN TREATMENT
In contrast to the traditional opinion that longterm counseling for alcohol abuse is always necessary, there is increasing evidence that brief intervention, delivered by a physician, can reduce effectively alcohol use by persons at risk for alcohol related problems. Several studies conduct ed in European and other countries in the 1980's demonstrated 10 to 20 percent reductions in alcohol use in members of experimental groups who were given advice by general practitioners, compared with members of control groups who received no guidance (Kristenson et al. 1983;Saunders et al. 1993). These find ings are consistent in more than 10 trials (Saunders et al. 1993). Effectiveness rates for brief intervention methods are similar to those of traditional alcoholism treat ment programs with atrisk drinkers.
In a brief intervention, the physician offers a clear message to a patient about reducing alcohol consumption, often delivered in the context of a health, social, or family problem or concern (e.g., "I'm concerned about your stomach pain, and I think your alcohol use may be a part of the problem."). Based on clinical judg ment regarding the seriousness of the presenting problem, the family practition er will determine if the patient's problem warrants abstinence or a reduced level of drinking. To accomplish this, the physi cian might say, "I want you to stop drink ing any alcohol for the next month so we can see if your stomach pain decreases" (if the patient cannot abstain despite medical problems, this indicates a more serious alcohol problem requiring follow up); or "I want you to reduce your alcohol use to no more than one drink every other day. How do you feel about the amount?" (this provides an opportunity for some minor negotiation about the amount and can be completed in a structured 15minute office visit).
Brief intervention also may involve giving the patient a pamphlet or selfhelp booklet, conducting followup telephone calls (usually 2 weeks after an office visit to determine if the patient is able to keep to the agreedupon alcohol limit and to handle any problems that have arisen), and seeing the patient for followup visits to support behavior changes (usually at 1 month intervals).

SPECIALIZED TREATMENT AND REFERRAL METHODS
Patients who require specialized treatment have an increasing number of options. Alcoholics Anonymous and other 12step models are still the most common founda tion for treatment and longterm recovery. However, within the last 10 years, the alcohol field has moved away from the standard 28day inpatient program, often called the Minnesota model, to several other models. These include not only traditional AAbased day and evening programs but also clientcentered treat ment that uses cue therapy, cognitive behavioral therapy, and motivation en hancement approaches. These approaches often use workbooks and other methods that include reasons to cut down or quit drinking, guides to risky situations, ways to cope with these situations, and ways to maintain treatment momentum.
Trends in treatment reflect a greater freedom of choice in treatment options. Providers are becoming increasingly oriented toward individualizing treatment for patients depending on their motivation to change, the presence of psychiatric and medical problems, and any family issues.
Patients who display physical depend ence, severe alcoholrelated health prob lems, and severe social disorders or are unable to change drinking behavior should be referred to an alcohol and other drug problems treatment specialist by their family physician. The physician can use several methods to identify such specialists in the community: • Ask colleagues for names of treatment programs or individual providers.
• Contact an alcohol problems treatment specialist or program, mental health center, and/or hospital for consultation about a patient's problem.
• Call the State alcohol and drug abuse agency for a list of the publicly and privately funded treatment programs in the State.
• Consult employee assistance programs in the area.

• Complete the Alcoholism Treatment
Resources Guide that lists the tele phone numbers of key professionals in the community (table 2). This re sources guide could be posted in the nursing station, the reception area, or an examining room.
When referring a patient to a special ist, the family physician should: • Advise the patient that a second opin ion from a specialist should be obtained.
• Make telephone calls to alcohol prob lems specialists while the patient is in the examining room or have the patient make the appointment before he or she leaves the office.
• Ask specialists to call once they have evaluated patients. This allows family practitioners to participate in the treat ment planning and support longterm behavioral change.
If patients refuse to see an alcohol problems treatment specialist or do not have financial resources, the family physician can: • Identify recovering alcoholics in the physician's own practice who are will ing to meet with atrisk drinkers and alcoholics to discuss methods they can use to change their drinking behavior.
• Ask patients to attend mutualhelp group meetings such as AA. Patients should be advised that they may have to attend several meetings in different locations to find compatible groups that fit their needs. Group meetings that do not use a 12step approach include Rational Recovery and Women for Sobriety.

FUTURE ROLE FOR FAMILY PHYSICIANS
Family physicians may assume an in creasingly important role in the care of their patients with alcohol problems (Skinner 1990;Prochaska and DiClemente 1992) and can make a difference in sever al areas. They can: • Establish effective screening proce dures to identify atrisk drinkers and those who meet criteria for dependence.
• Conduct brief interventions with pa tients who meet the cutoff criteria for atrisk drinking.
• Ask an alcohol and other drug prob lems treatment specialist to conduct assessments and counseling in the primary care office.
• Identify affected members of families and provide treatment and referral.
• Use pharmacotherapy for craving, drug maintenance, and detoxification.
• Appropriately treat the recovering patient's medical, surgical, or other needs to avoid prescribing mood altering and addictive drugs.
Models for screening, assessing, and advising patients regarding alcohol use are available to assist family physicians in the management of one of the most prominent health care problems in the United States. As evidence supporting the effectiveness of screening and brief inter ventions causes trends in the treatment of alcoholrelated problems to shift, the role of family physicians in the care of their patients with alcohol problems may be broadened. ■